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Emotions and emotional disorders
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Emotions and emotional disorders
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Emotions and emotional disorders
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Contents

Introduction

Learning outcomes

1 Moods, emotions and disorders
 1.1 What is an emotional disorder?




1.2 Occurrence and cost of emotional disorders
2 Emotions in an evolutionary context
 2.1 An evolutionary approach to emotion in humans and
animals

2.2 Evidence for the universality of human emotions

2.3 Evolutionary layers of the brain

2.4 The amygdala and emotion

2.5 The value of negative and positive moods and emotions

2.6 The pressures of modern life

2.7 Social competition, stress and subordination in animals

2.8 Social competition, stress and subordination in humans
3 Recognising emotional disorders
 3.1 Diagnostic criteria for emotional disorders

3.2 Affective disorders

3.3 Diagnosing major depression (MD)

3.4 Anxiety disorders

3.5 Experiencing anxiety

3.6 Diagnosing generalised anxiety disorder
4 Challenges in the diagnosis of depression and anxiety
 4.1 Are the diagnostic categories correct?

4.2 Medicalising sadness?

Conclusion

References

Acknowledgements
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Introduction
This course is about stress, emotional disorders and the brain. You will learn about
some of the disorders related to the feelings of stress, sadness and anxiety including
how these disorders are diagnosed, their biological correlates, and evidence of their
possible causes. To start, the course looks at some definitions of mood, emotions and
emotional disorders and explains how emotions and emotional disorders themselves
can be placed in the wider context of our evolutionary heritage.
This OpenLearn course is an adapted extract from the Open University course
SDK228 The science of the mind: investigating mental health.
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Learning outcomes
After studying this course, you should be able to:





recognise the value of an evolutionary perspective in understanding
emotions (or moods) and emotional (or mood) disorders
specify brain pathways involved in the perception and processing of
emotions
describe the rationale of approaches used in the diagnosis of emotional
(or mood) disorders
outline the characteristics and experience of specified emotional
disorders
demonstrate understanding of information about the prevalence of
mental health disorders in populations.
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1 Moods, emotions and disorders
Mood, like emotion, is an affective state or in layman’s terms; ‘a feeling’. Those in
favour of a distinction between the terms ‘mood’ and ‘emotion’ suggest that emotion
has a clear focus (i.e. its cause is self-evident), whereas mood is diffuse and can last
for days, weeks, months, or even years.
Other researchers use the terms ‘emotion’ and ‘mood’ interchangeably. The basic
disagreement seems to be about whether it is important to recognise that one state
(emotion) is normally associated, by the person experiencing it, with a particular
object or cause, and the other (mood) is often not. What difference might this make?
Some evidence suggests that a particular ‘mood’ can affect our thoughts, perceptions
and behaviours for prolonged periods – the so-called ‘mood effect’.
There is evidence that when a mood or its source is brought to the attention of the
person experiencing it, the mood effect can disappear (Schwarz, 1990). So it has been
suggested that although moods (like emotions) can have identifiable sources, the
effects of moods depend on the sources going unnoticed; and that a distinction
between moods and emotions is therefore meaningful and even useful.
Certainly, it may help our understanding of some kinds of treatment for affective and
anxiety disorders. For instance, mindfulness-based or cognitive therapy approaches
may exert their effect by training people to become more aware of their moods, and of
what is influencing or causing them.
Another common distinction found in the study of moods and emotions concerns
states and traits. A trait is a relatively stable attribute of an individual, whereas a state
is a temporary response to circumstances.
Take, for example, anxiety. A person shows state anxiety when something causes him
or her to feel anxious temporarily. The anxiety then dissipates and the person feels
‘normal’ again. An example might be the anxiety that some people feel when heading
to an appointment with the dentist, or waiting for an operation. However, in some
people anxiety is a trait – they can simply be described as ‘anxious people’. Trait
anxiety has therefore been suggested to be a relatively stable characteristic of a
person.
While traits may indeed be more stable, it does not mean that they are not malleable,
at least to some extent, though perhaps they are harder to change.
1.1 What is an emotional disorder?
The terminology used to classify mental health disorders like emotional disorders has
developed and changed over many decades. Multiple usages are current and can be
very confusing. ‘Affect’ is another term for ‘mood’, so one term often used is
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‘affective disorders’ which simply refers to ‘mood disorders’. Depression (also known
as major depression or MD) is the most commonly occurring of the set of mood
disorders known as affective disorders.
A set of disorders that are clearly distinguished from those falling under the term
‘affective disorders’ is anxiety disorders. These have in common a strong element of
fearfulness, apprehension or anxiety and include generalised anxiety disorder (GAD),
panic disorder, phobias, and obsessive–compulsive disorder (OCD). It may puzzle
you that the ‘affective disorders’ do not include anxiety disorder(s), even though
anxiety is certainly an emotion! This is simply an anomaly rooted in the history of
terminology in this area. However, the anxiety and affective disorders are collectively
often referred to as emotional disorders, and this is therefore the term that will be
adopted throughout the rest of this course.
1.2 Occurrence and cost of emotional disorders
Whilst anxiety and sadness are everyday emotions, their more serious manifestations
can be hugely problematic for a significant number of people.
National statistics compiled by the Government show that in England in 2007, 16.2%
(around 1 in 6) of 7325 adults between the ages of 16 and 64 years met the clinical
diagnostic criteria for at least one emotional disorder (or common mental disorder;
McManus et al., 2009).
Of these, depression and anxiety (or a mix of the two, called ‘mixed anxiety and
depression’ or MAD) were by far the most common, as Figure 1 shows. Note that the
term prevalence is a scientific term that refers to the number of people experiencing a
disorder or illness at a particular time.
Figure 1 Prevalence rates in England in 2007 of a range of emotional disorders (also known as common
mental disorders) by gender. MAD: mixed anxiety and depression; GAD: generalised anxiety disorder; MD:
major depression; OCD: obsessive compulsive disorder.
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View description - Figure 1 Prevalence rates in England in 2007 of a range of
emotional disorders (also ...

Why do you think we consider that the data in Figure 1 show
prevalence rates and not simply prevalence as defined in the
paragraph above?

Because they show the number of people who have emotional
disorders, expressed as a rate per 100 (i.e. a percentage) of the
population. Prevalence would just tell us the total number of people
with emotional disorders in the population.
The burden to society as a whole is therefore considerable, as anxiety and depression
are implicated in 20% (1 in 5) of days lost from work in Britain, and around one in
five GP consultations in the UK are about emotional disorders.
Depression has also been linked to the loss of more than 100 million working days in
England every year, and it is strongly associated with suicidal thoughts and with
suicide, being implicated in around 2500 deaths a year (Thomas and Morris, 2003).
McCrone et al. (2007) estimated the total annual cost of depression, including lost
employment, in England as at least £7.5 billion a year.
Clearly, it is therefore important to try to understand both emotions and emotional
disorders. We start this process here by looking at the nature of emotions and
emotional systems.
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2 Emotions in an evolutionary context
Like other living things, people are the products of millions of years of evolution. An
evolutionary approach thus has the potential to provide a number of important insights
into the nature and function of emotions and emotional systems, and can enhance our
understanding of what constitutes mental health and ill-health more broadly (Marks
and Nesse, 1994; Nesse, 2006).
The evolutionary approach postulates that many of our physical, mental, social,
emotional and spiritual characteristics and tendencies exist because they were useful
or even essential in enabling our ancestors to survive and reproduce more successfully
than their competitors. In other words, such characteristics and tendencies were
adaptive; helping us to adapt to survive.
It is important to realise that evolutionary processes build on, or modify, what is
already there – they cannot start from scratch. The changes brought about by
evolution are a bit like remodelling your home over time. You may have installed
electricity in your ancient cottage, but the low beam at the bottom of the stairs is part
of the core structure of the building and cannot be removed. So, though you need to
bend a bit to avoid banging your head on it, you just have to live with it. In the same
way, we retain a great deal of the machinery and modes of operation of many of our
ancestors. For instance, parts of our brain, particularly those parts associated with
emotions have a similar structure and organisation to that of many other animals. We
will explore this later on in the section.
2.1 An evolutionary approach to emotion in
humans and animals
The evolutionary approach suggests that non-human animals, our evolutionary
relatives, experience emotions too. Anybody who has a pet dog or has observed any
animals carefully should need no convincing of this! Charles Darwin was one of the
first to study the expression of the emotions in animals and humans systematically
(Darwin, 2009 [1872]). Figure 2 shows a dog expressing two rather different emotions
– aggression and fearfulness (or submission).
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Figure 2 Dog showing (a) aggressive and (b) fearful postures.
View description - Figure 2 Dog showing (a) aggressive and (b) fearful postures.
Activity 1 Identifying features of different emotions
Allow 5 minutes
Look carefully at the two pictures of the dog and list the main differences you can see
between the aggressive and the fearful postures.
View answer - Activity 1 Identifying features of different emotions
It is striking how different the postures are. Indeed, diametrically opposite emotions
appear to have evolved features that make it very easy to tell them apart. Similarly, a
happy face is normally easy to distinguish from an angry one. Such features suggest
that the expression of emotions has an important function in social communication –
for instance, in letting others know how we feel and what the consequences, pleasant
or unpleasant, might be if they approach us.
A consequence of the evolutionary heritage we share with other animals, in particular
mammals such as rats, and even more so, monkeys and apes, is that there is
significant similarity in the biological bases of many of our emotional response
systems, as you will see in Sections 2.3 and 2.4.
The evolutionary approach also suggests the universality of human emotions – an idea
again first clearly espoused by Darwin (2009 [1872]). This is the idea that all human
races and cultures experience similar emotions, such as sadness, anger and joy. This
has not always been accepted, which is not surprising, as cultural differences amongst
humans have created strikingly different behaviours and displays of emotions in
circumstances that appear otherwise comparable. A classic example is provided by
cultural differences in the public expression of emotion at the death of a loved one. In
traditional Japanese culture, weeping and wailing in public would be deemed
scandalously uncontrolled and undignified. In others (such as traditional Indian
culture), the absence of such behaviour might be deemed equally scandalous –
signifying a lack of feeling for, and attachment to, the deceased.
Differences such as these led to the assumption that people in different cultures did
not feel the same emotions, or did not feel them in the same way (e.g. Bruner and
Tagiuri, 1954). However, there is convincing evidence of the universality of basic
human emotions.
2.2 Evidence for the universality of human
emotions
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Paul Ekman and his colleagues showed photographs of North Americans displaying a
range of emotional expressions to people, such as the Fore of New Guinea, who had
had virtually no contact with Westerners. They wanted to know which expressions the
Fore would identify as (say) those of a man who had lost his child.

Why was it important that the Fore people had had minimal contact
with Western culture?

To ensure that they had not simply learned about the relationship
between the expressions in the photos and the emotions that the
photos represented, via contact with Western culture.
The Fore did prove competent at identifying emotions in Western faces. Ekman and
his colleagues also photographed responses to emotional situations in the Fore, and
this time asked North Americans to assess them – which they did, also accurately.
Ekman concluded that recognition and expression of emotions was shared across
cultures, at least for the six emotions he felt were ‘basic’: happiness, surprise, sadness,
anger, fear and disgust; see Figure 3.
Figure 3 Photographs showing facial expressions for the six basic emotions. Top row, left to right:
happiness, surprise, fear. Bottom row, left to right: sadness, disgust, anger.
But explanation was still needed for the fact that people from different cultures
sometimes showed different expressions in circumstances where one would expect
them all to show a particular emotion, such as sadness. Ekman suggested that this was
because different cultures learned different ‘display rules’ for emotions. For instance,
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Japanese culture has a display rule that emotions such as anger or disgust must not be
expressed in front of people of higher social status, whereas North American culture
does not have such a rule. When Japanese and Americans were secretly observed
watching a gory film, both showed facial expressions of disgust. When they were
shown the film in the presence of a person with higher social status, the Japanese
smiled, but the Americans still showed facial expressions of disgust.
Based on such findings, Ekman (1972, 2003) proposed his neurocultural theory of
emotions. This suggested that certain human emotions were universal, but that the
facial expression of these emotions could be influenced by social learning via local
culture. (‘Culture’ is used here to mean practices or ways of thinking, so the term can
apply widely, at different levels. Thus there could be ‘cultural’ differences between
socio-economic classes, between men and women, and so on.)
All in all, therefore, sadness and anxiety have the same biological bases in all humans,
and are experienced in fundamentally similar contexts – thus bad feelings are reliably
aroused by losses, threats of losses, and the inability to reach important goals
(Emmons, 1996).
However, culture does have an effect. It can affect what we regard as important goals
or losses and therefore what triggers our emotions. Thus in Westernised societies
some women may feel anxious and depressed at not being as thin as their culture
considers desirable. In some Asian cultures, where male offspring are greatly prized,
some women who give birth to one daughter after another may feel great despair and
anguish. Cultural factors may also come into play in how acceptable people find it to
display emotions and to admit to feelings, particularly negative ones. As diagnosis of
emotional disorders is reliant on subjective report and assessment by interviewers, it
is easy to see how cultural factors could impact on the diagnosis of problems like
depression and anxiety (Section 4).
Our basic emotions, however, are those that all humans feel, and underlying them are
brain structures and connections that are not just common to humans but have an
ancient lineage, as explained in the next section.
2.3 Evolutionary layers of the brain
A well-known model for understanding the basic structure of the human brain was
developed by Paul MacLean in the 1960s (see Maclean, 1990). He called it the triune
brain and suggested that three distinct brains emerged successively in the course of
evolution and now coexist in the human skull. (It was mentioned earlier that evolution
could not start building a structure from scratch – this is a good example!). We
suggest that if you are not already familiar with the basic anatomy of brains then you
spend a few moments exploring the brain using the interactive brain resource
associated with this course before you examine MacLean’s three brains model below.
(Note that you need to sign in to the website to use this resource.)
The ‘three brains model’ proposed by MacLean (Figure 4) were:
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1. The so-called reptilian brain, the oldest of the three in evolutionary
terms, which controls the body’s vital functions such as heart rate,
breathing, body temperature and balance. The main structures here
are the brainstem and the cerebellum. One characterisation of the
reptilian brain calls it ‘reliable but somewhat rigid and compulsive’.
2. The limbic brain. This is also an evolutionarily ancient part of the
brain and is found in mammals (such as rats, cats, dogs, monkeys,
etc.). In the so called ‘limbic brain’ there is the amygdala, which
registers unconscious memories of behaviours that produced pleasant
or frightening experiences, and is closely linked to emotions, along
with the thalamus, hypothalamus and hippocampus. The limbic brain
has been characterised as ‘the seat of the value judgments that we
make, often unconsciously, that exert such a strong influence on our
behaviour’.
3. The neocortex (the ‘new cortex’) evolved more recently in primates
such as monkeys and apes, our closest relatives. It constitutes most of
the cerebral cortex, which is highly developed in humans, with two
large cerebral hemispheres. The neocortex, is thought to underlie
language, abstract thought, imagination, consciousness and the
development of culture and has been characterised as ‘flexible, with
almost infinite learning abilities’.
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Figure 4 The triune brain, showing the so-called reptilian brain, the limbic brain and the neocortex.
View description - Figure 4 The triune brain, showing the so-called reptilian brain,
the limbic brain ...
Some neuroscientists find the ‘triune’ brain model simplistic and misleading.
Certainly, it should not be taken literally. For instance, the ‘reptilian’ brain is not a
distinct entity, identical to that of reptiles, within our own human brains. And our socalled ‘three brains’ do not operate independently of one another – we have one,
highly interconnected brain, with different areas communicating with and influencing
one another continually.
However, the triune brain concept is helpful in understanding that the influence is not
always fully reciprocal – ‘older’ parts of the brain such as the limbic brain appear to
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have a stronger influence on the ‘newer’ parts than vice versa. For instance, neural
pathways sending messages from the amygdala to the prefrontal cortex (PFC) which
is part of the neocortex are extensive, but pathways sending messages in the opposite
direction are relatively sparse.
As you will see if you look at the related OpenLearn course Understanding
depression and anxiety, this has significance for the conscious control we can exert
over our emotions.
2.4 The amygdala and emotion
The amygdala, a structure in the limbic brain, plays a central role in our emotional
perception and our responses (LeDoux, 1998). The amygdala has a similar role in
other mammals such as rats and monkeys – this is important and relevant, given the
use of animal models in scientific studies to study several aspects of issues related to
emotions and emotional disorders, as will become clearer if you study the related
OpenLearn course Understanding depression and anxiety.
Parts of the amygdala are involved in triggering the responses we associate with fear,
such as submission, fleeing, or staying rooted to the spot (i.e. freezing). Other regions
elicit feelings of ‘bliss’ or peacefulness, while still others evoke aggression and attack.
Life-or-death situations demand extremely rapid responses, which the amygdala is
well-placed to mediate. For instance, if you are out walking at night in an unfamiliar
neighbourhood and hear a sudden thump behind you it may make you jump in alarm.
Your heart will be beating hard and all your senses will be alert – because your ‘fight
or flight’ reaction has been triggered. Information from the senses (from hearing, in
this case) reaches the amygdala, which triggers the ‘fight or flight’s stress response.
There are two routes via which this sensory information can get to the amygdala
(Figure 5).
One route, known as the ‘low road’ or the ‘quick and dirty’ route, carries relatively
crude information from the ear to the amygdala via the thalamus: ear → thalamus →
amygdala. This is the subcortical route – i.e. it is ‘below the cortex’ and is fast and
unconscious – a response is triggered in a split second before you are aware of what
actually made you jump. The other route, the ‘high road’ is a cortical route, as it goes
via the cortex: ear → thalamus → cortex → amygdala. It is longer, slower and
indirect, but provides more detailed information about the stimulus, and allows
conscious awareness and assessment of it. So you may feel rather sheepish, on
realising that it was just a cat jumping onto a dustbin!
The quick unconscious route elicits an ‘automatic’ reaction around a fiftieth of a
second (20 milliseconds or thousandths of a second) after the sound enters your ear.
The longer, slower route via the cortex takes 200 milliseconds (a fifth of a second) –
this is how long it takes before you are consciously awareness of what made you
jump. This is still very quick, but the unconscious route is 10 times faster.
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Figure 5 Information about emotional stimuli reaches the amygdala via a direct pathway from the thalamus
(‘low road’) as well as by a pathway from the thalamus to the cortex (‘high road’) to the amygdala.
View description - Figure 5 Information about emotional stimuli reaches the
amygdala via a direct pathway ...
The above also shows that our emotions can be triggered extraordinarily rapidly and
unconsciously. If we are in a very ‘reactive’ state, we may find ourselves responding
emotionally to situations and stimuli without thought or judgement, perhaps with
disastrous results. Fortunately such initial and unconsciously triggered emotional
responses can be modified and corrected by conscious appraisals into more
considered and appropriate responses. For instance, if someone knocks into you, your
response will depend on whether you think the person did this deliberately or
accidentally.
We will revisit the role of appraisal, and of the amygdala in emotional responses, in
the related OpenLearn course Understanding depression and anxiety.
Activity 2 The pathways of the fear reaction
Allow 5 minutes
Following a sudden sound, which of the following pathways, A to E, provides (a) the
unconscious route that mediates the fear reaction; (b) the conscious route that
mediates the fear reaction and also allows appraisal of the stimulus that caused the
fear?
A. ear → amygdala → cortex → hippocampus → emotional response
B. ear → orbitofrontal cortex → thalamus → emotional response
C. ear → thalamus → amygdala → emotional response
D. ear → thalamus → cortex → emotional response
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E. ear → thalamus → cortex → amygdala → emotional response.
View answer - Activity 2 The pathways of the fear reaction
2.5 The value of negative and positive moods and
emotions
An evolutionary approach allows us to be open to the idea that negative as well as
positive emotions have value. This is obvious for some negative emotions such as fear
and anxiety; for example, in the context of escaping from a bear. It is not so obvious
for sadness, or worry (a form of fear and anxiety about the future).
It has been suggested that sadness can be useful in some circumstances and hence
have an ‘adaptive’ function. For example, it might make individuals reconsider
problems such as failed goals, and lead them to abandon unhelpful ways of behaving
or of doing things (e.g. Oatley and Johnson-Laird, 1987). To use a physical analogy,
pain is unpleasant and aversive but is considered adaptive as it can benefit an injured
individual by preventing further harm or damage.
That low mood can indeed be useful is shown in a series of studies carried out by the
psychologist Joseph Forgas and his team at the University of New South Wales. They
found that, while performing a task, people in whom a sad mood had been induced
paid more attention to details, were less gullible, less likely to make errors of
judgment, and were more likely to come up with high-quality, persuasive arguments
than people in whom a good mood had been induced (Forgas, 2009). Good or bad
mood can be induced in people by, for instance, showing them happy or sad images or
films.
Worry, too, can be useful. Psychologist Graham Davey of the University of Sussex
found that although worrying sometimes made things worse for participants in his
study, it often motivated them to take action and resolve problems and this in turn
reduced anxiety (Davey, 1994). Similarly, McCaul et al. (2007) found that cigarette
smokers were more inclined to stop smoking if worried about the risks of smoking.
Overall, such findings suggest that mild to moderate levels of worry can be beneficial,
motivating people to put in the bit of extra effort and attention needed to make a
success of their endeavours.
Conversely, an evolutionary stance allows for the possibility that emotions we
consider desirable may not be universally (i.e. in all circumstances) ‘good’ or
appropriate. While there is evidence that positive mood facilitates creativity,
flexibility and cooperation there is also evidence that misplaced optimism can lead to
rash decisions and risk-taking (Alloy and Abramson, 1979).
Aversion and approach are facilitated by different emotions. Low and high mood may
be useful in certain situations but may be very unhelpful in others.
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2.6 The pressures of modern life
A number of studies (for instance in countries such as the USA) suggest that people
currently feel more anxious and stressed than in the 1950s, despite unprecedented
improvements in physical health and wealth (e.g. Twenge, 2006). Perhaps this reflects
increasing dissatisfaction with the pressures of modern industrial societies, in which
the pace of change has been accelerating for many decades.
Some researchers suggest that modern life itself is particularly stressful and happiness
particularly elusive, because we live in a very different world from that in which we
evolved. Culturally, humans have come a long way from their ancestors. Only 30–
50 000 years ago our ancestors lived in small kin-groups as hunter-gatherers (Figure
6).
Figure 6 Hunter-gatherers today: A group of Khoisan people of the Kalahari desert singing and dancing
around their campfire.
View description - Figure 6 Hunter-gatherers today: A group of Khoisan people of
the Kalahari desert ...
This time span of a few tens of thousands of years, though it may appear long, is not
in fact sufficient to allow significant biological evolution, though it has witnessed a
tremendous explosion of cultural evolution. Our brains and emotional propensities, on
this account, remain more or less as they were in our ancestors. In Eaton et al.’s
(1988) memorable phrase, modern people are like ‘stone-agers in the fast lane’.
What are the implications of this for our well-being? Physically, it has been suggested
that many of our chronic health problems, for example atherosclerosis (hardening of
the arteries), diabetes, high blood pressure and the complications of smoking and
alcohol abuse, result from the mismatch between the environment in which we
evolved (sometimes referred to as the environment of evolutionary adaptation or
EEA) and the environment in which we currently live. For instance, we have an
evolved propensity to prefer sweet and fatty foods – this would have been valuable for
survival in the past, when these energy-rich foods were rare. Now, in an environment
of easy availability and little energy expenditure, indulging this preference can lead to
obesity and diabetes, with their often harmful consequences.
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Mentally and emotionally, too, many people, particularly in urban areas and the
industrialised world, now live in a hugely different environment. For instance, many
of the expectations that people face from their families, employers and society, and
the perceived pressures from advertising and media to achieve goals of fame, beauty
and success are unrealistic and unachievable for most people. This can be highly
stressful and demoralising. On this view, the complexity of modern goals and the
difficulty and effort needed to achieve many of them play a very significant role in
feeding negative emotions such as anxiety and depression.
Some people have linked such pressures to the consumer and individualist attitudes in
modern industrial societies (e.g. Twenge, 2006). Indeed the distinguished stress
researcher Robert Sapolsky of Stanford University argues that the ‘epidemic’ of stress
and stress-related mental distress in Western societies, which are hugely rich and
privileged compared to the rest of the world, is strongly linked to psychological
factors: ‘We’re ecologically privileged enough that we can invent social and
psychological stress’ (Sapolsky, 1998).
As we consider in the related OpenLearn course Understanding depression and
anxiety, the effect of chronic stress can be very deleterious for some people.
2.7 Social competition, stress and subordination in
animals
The behavioural tendencies of animals in situations of defeat and outranking, and
hierarchies, have inspired insights into human mental health and well-being.
Living in a group entails competing with others for desirable resources such as food
and mates. In many species such competition has led to the development of status
hierarchies. Anyone who keeps chickens is well aware that there is a strongly
enforced ‘pecking order’ amongst the hens. This was one of the first dominance
hierarchies amongst animals to be described by scientists, and the term ‘pecking
order’ was coined in this context.
Animals who accept subordination avoid fights with dominants; indeed they show
clear signals of submission and readily cede space and resources to dominants. They
may suffer harassment, displacement and bullying or scape-goating attacks from
others (Figure 7, Figure 8).
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Figure 7 Rhesus macaques: the infant son of a subordinate female (who is out of the frame) has been
kidnapped and is being mistreated by a dominant female. The infant was distressed and his mother agitated
but unable to intervene to rescue him. After some hours the subordinate female managed to snatch her baby
back when the dominant female let go of him.
View description - Figure 7 Rhesus macaques: the infant son of a subordinate female
(who is out of ...
Figure 8 A young male rhesus macaque wounded in a fight with other males showing submissive posture
and fear grimace.
View description - Figure 8 A young male rhesus macaque wounded in a fight with
other males showing ...
Why do animals accept subordination in a hierarchy? The simple answer is that
strongly social animals normally have no choice. They may be beaten in a fight by a
stronger animal or an alliance of animals. But they may be better off remaining in the
group because life alone, outside the group, may be even more stressful and
dangerous than life as a subordinate. Being in such situations can be very stressful for
animals, affecting the levels of stress hormones in their blood, their reproductive
systems and their cardiovascular health (Sapolsky, 1998).
Animals that have been beaten and outranked typically give up – they readily respond
in a submissive way to dominant animals, rather than fighting back. This appears to
be an evolved, adaptive strategy to being defeated (in situations where rebellion is
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most unlikely to succeed): it is better to cut one’s losses and accept the status quo than
to continue fighting and risk injury or even death.
How is this relevant to human mental health? We explore this in the next section.
2.8 Social competition, stress and subordination in
humans
Status hierarchies are deeply ingrained amongst humans, and social and economic
hierarchies and inequalities within and between societies have powerful consequences
for poverty, self-esteem and health, including mental health (Wilkinson and Pickett,
2009).
Humans also appear highly sensitive to situations that parallel, or are analogous to,
outranking and defeat in animals such as monkeys. The clinical psychologist Paul
Gilbert (Gilbert 1989, 1992), building on the suggestions of Price and Sloman (1987),
suggests that ‘evolutionary-based “social mentalities” that involve ranking and power
are activated in depression’. Essentially he believes that depression is a state like that
of an outranked, defeated monkey, and is likely to be provoked by situations of loss
where a person feels ‘helpless and powerless, seeing no way forward’. Gilbert
suggests these are also situations in which people are likely to feel humiliated and
ashamed.
In support of these suggestions, there is evidence that the situations people find most
stressful are ‘social evaluation’ situations, where not only might they fail, but they
will be seen to fail – that is, situations where public humiliation is a possibility. For
instance, Dickerson and Kemeny (2004) reviewed studies of cortisol levels in people
placed under different kinds of stress. They found that people’s cortisol levels were
highest in situations where their performance was likely to be assessed in public and
where they felt they had no control over their performance (Figure 9). (See Box 1 for
an explanation of the type of data shown in Figure 9.) Some of the changes in cortisol
levels shown in Figure 9 were statistically significant. Statistical significance means
that a mathematical test has been applied to the results and has shown there to be a
difference that is ‘real’; in other words, a difference that is most unlikely to have been
obtained by chance. When scientists report that the results are significant, they mean
that they are statistically significant.
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Figure 9 Mean (+/− SEM) change in cortisol levels in potentially stressful situations. Values above 0.0
indicate a rise in cortisol levels. * denotes that the change is statistically significant. Key to terms: Passive
tasks –tasks such as watching a film that do not require cognitive responses; Motivated performance – tasks
such as delivering a speech or solving an arithmetical problem that require cognitive responses and
achievement of a goal; Uncontrollability – a situation of ‘forced failure’ where participants have no chance
of succeeding despite their best efforts, for example where too little time is given to complete a task; social
evaluative threat – occurs when an aspect of self (such as ability) could be negatively judged by others.
View description - Figure 9 Mean (+/− SEM) change in cortisol levels in potentially
stressful situations. ...
Gilbert (1989) suggested that what would be most likely to lead to depression would
be:
situations of direct attack on a person’s self-esteem that forced the
person into a subordinate position
 events undermining a person’s sense of rank, attractiveness and value,
particularly via the consequences of the event for roles (for instance,
as a mother or professional) that the person held dear; and
 blocked escape.

Testing these ideas, Brown et al. (1995) found that humiliation and entrapment were
indeed the most powerful provoking events for the onset of major depression in their
study population of women (Table 1; see also Box 2 for definitions of humiliation,
etc.).
Table 1 Onsets of major depression by type of provoking event within the six months
before onset of depression. (Modified from data in Brown et al., 1995.)
Psychosocial
Number of events
aspects of life event that occurred in this
category
Humiliation and
entrapment
Number (and %) of events in this
category that provoked onset of
major depression
131 41 (31%)
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Loss alone
Danger
Total
157 14 (9%)
89 3 (3%)
377 58 (15%)
The differences shown Table 1 are highly statistically significant.

From Table 1, what is the second most powerful provoking kind of
event for the onset of depression?

Loss alone – 9% of such events led to depression.
Box 1 Research methods: analysis of scientific data – descriptive
statistics
The data in Figure 9 are shown as the mean change in the concentration of cortisol in
the blood, plus the SEM (standard error of the mean, which is generally written as +/−
SEM) You will probably be familiar with the term ‘mean’ which is calculated by
adding up all of the data from a group of participants and dividing the total by the
number of participants. The mean is sometimes referred to as the average and it
allows simple comparisons to be made from one group to another. For example, you
can easily see that the mean results for those in a situation of ‘motivated performance
with social evaluative threat and uncontrollability’ are very different for the results for
those in a situation of ‘motivated performance with uncontrollability’. However, the
mean is a summary of the data obtained and can mask considerable variation within
the data. The size of the mean does not tell you anything about the range of the data,
in other words the lowest and the highest values. It is possible that some of the values
obtained in the first group above were the same as values obtained in the second
group above. The second problem with the mean is that it can be distorted by one
value that is much higher or lower than the rest of the values obtained for the group.
For these reasons, sometimes different ways of summarising data are used, which give
a different picture of the data. The first of these is the median, which is found by
ranking the data in order of value and taking the middle value (median values are
shown in Figure 13). The second is the mode, which is the value that occurs most
frequently. The mean, median and mode are sometimes referred to as ‘measures of
central tendency’.
Most scientific data in this course, however, are presented in the form of a mean. In
order to make sense of differences between means, researchers calculate an additional
statistic which takes account of the pattern of the observed values, known as the
variance. The variance is calculated from the differences between each value and the
mean, so the more values there are that are much higher or lower than the mean, the
greater the variance will be. The variance is usually quite a large figure relative to the
mean value, so the square root of the variance is often used, known as the standard
deviation (SD). The SD therefore gives an idea of the spread of data about the mean.
Alternatively, a further calculation is performed, which takes into account the number
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of participants, giving a SEM. The SEM gives an idea of the accuracy of the mean, or
how close it is to the true population mean. Data is usually presented in the form
mean ±SD or mean ±SEM. In graphs, the SD or SEM is usually shown as a small bar
(line with a flat top) above and below the mean value, as shown in Figure 9.
In summary, descriptive statistics such as the mean, SD and SEM, are used to
summarise quantitative data and provide useful information about the values and
spread of data obtained in different groups. They allow comparisons between groups.
They do not, however, allow any meaning or significance to be inferred from these
observations; this requires the application of a relevant statistical test.
Box 2 Psychosocial dimensions of life events
(Modified from Kendler et al. (2003))

Loss: for example, a real or anticipated loss of a person, a material
possession, employment, health, respect in the community or a
cherished idea about oneself or someone close to oneself.
 Humiliation: feeling devalued in relation to others or against a core
sense of self, usually with an element of rejection or sense of role
failure.
 Entrapment: ongoing circumstances of marked difficulty of at least 6
months’ duration that the subject can reasonably expect will persist or
get worse, with little or no possibility that a resolution can be
achieved as a result of anything that might reasonably be done.
 Danger: the level of potential future loss, including both the chance
that a given traumatic event will recur or a possible sequence of
circumstances in which the full threat or dire outcome has yet to
occur.
In the following section we consider emotional disorders, such as major depression,
further.
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3 Recognising emotional disorders
We all have set-backs that can make us feel low, sad or anxious. What is the
difference between these states, and states of low mood that are officially considered
to be disorders? You might be surprised to learn that in real life there is no clear
dividing line to distinguish ‘normal’ from the disordered experience of these
emotions, However, we often know when all is not as it should be. First-person
accounts, or personal narratives like the one given in Vignette 1 are illuminating in
this regard.
Vignette 1 An experience of depression: Lewis Wolpert
Professor Lewis Wolpert (1929–), a distinguished British biologist, generally stable,
happily married and with a good job at a university, descended into what was
diagnosed as an episode of severe depression. A self-confessed hypochondriac, in the
weeks before the episode he had been anxious about the effects of a new drug
(flecainide) prescribed by his cardiologist to control his long-standing irregular
heartbeat or atrial fibrillation. (The old drug, which he had taken for several years,
had become ineffective.) He speculates that this change may have triggered his
depression. The new drug gave him morning sickness and severe stomach cramps,
which accentuated his hypochondriac streak and made him fear he might have a
stroke. Worried, and against his doctor’s advice, he cancelled a trip abroad to a
science conference. Instead of making him feel better, this made him feel even more
distressed and anxious, as he felt he had let down his colleagues. He began having
difficulties sleeping and started to think a lot about death. Then one night he had a
dream about devils and woke up with a compulsion to kill himself. He writes:
[…] my mental state bore no resemblance to anything I had experienced before. I had
had periods of feeling low but they were nothing like my depressed state. I was totally
self-involved and negative and thought about suicide all the time. I just wanted to be
left alone and remain curled up in my bed all day. I could not ride my bicycle and had
panic attacks if left alone too long.
I also had numerous physical symptoms – my whole skin would seem to be on fire
and I would on occasion twitch uncontrollably. Each new physical sign caused
extreme anxiety. Sleep was very difficult and sleeping pills only seemed to work for a
few hours. The future seemed hopeless and I was convinced that I would never
recover and would probably end up completely mad
[…] I thought of suicide all the time but did not know how to do it. As I was too
scared of heights, jumping from my window which was high up was ruled out […]
Nothing gave me pleasure and every decision, no matter how small, increased my
anxiety. I had no emotions and was unable to cry but I did retain a macabre sense of
humor […] I got a bit better during the day and by evening could read and watch TV,
but next morning I was back in the original bad state […] My memory seemed to be
failing and I was frightened that I was going insane.
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(Wolpert, 2009, pp.1–2)
Figure 10 Lewis Wolpert (1929–).
View description - Figure 10 Lewis Wolpert (1929–).
Lewis Wolpert (Figure 10) found his recovery from the episode was tortuous,
involving drugs and psychotherapy. Wolpert was aware that 90% of those who suffer
a severe depressive episode have a relapse. Indeed, four years later some of the
symptoms of his depression recurred; once again he received treatment and recovered.
Since then he has suffered other episodes though none as severe as the first (Wolpert,
2009).
As Wolpert’s case shows, depressive episodes do not just include despair, they can
also include feelings of panic and anxiety. Indeed feelings of anxiety are almost
always present in depression, though anxiety can occur without depression.
3.1 Diagnostic criteria for emotional disorders
Formal diagnostic criteria exist to identify emotional disorders. Two international
examples are the DSM-IV-TR (APA, 2000) or ICD-10 criteria (WHO, 2007)). Such
systems are based on signs and symptoms, which psychologists sometimes group into
four categories:



mood or emotional symptoms, for instance feeling sad
motivational symptoms, such as difficulty making decisions
cognitive symptoms, involving thought, such as worry or pessimism,
and
 physical symptoms, such as bodily aches or pains.
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Diagnostic systems such as DSM-IV-TR have been criticised for a number of reasons,
some of which will be considered in Section 4. However, they have been very
influential, so it is important to consider them. They not only determine what
diagnosis a patient seeking help receives, they underpin a great deal of research work
into the causes and correlates of mental disorders.

How do diagnostic criteria underpin research work?

Researchers who are interested in (for instance) whether depression is
linked to changes in the brain need to compare the brains of people
who are and are not depressed. They often use DSM criteria to decide
who is or is not depressed – so these criteria will determine who falls
into each of the groups being compared.
Thus the process of diagnosis is clearly critical, as our understanding of emotional
disorders is fundamentally underpinned by how we decide who suffers from them.
DSM-IV-TR, which we will focus on here, splits emotional disorders into two
clusters, affective disorders and anxiety disorders.
3.2 Affective disorders
Affective or mood disorders include manic-depressive illness or bipolar disorder (it is
called bipolar because it has ‘two poles’: mania and depression). However, by far the
most prevalent affective disorder is major depression (MD), which accounts for 80–
95% of all depressions. Major depression is sometimes called unipolar disorder to
contrast it with bipolar disorder. In MD the individual suffers depressive symptoms
(for example sadness, hopelessness, passivity, sleep and eating disturbances) without
ever experiencing mania. In mania, the individual experiences symptoms of extreme
elation, expansiveness and irritability, talkativeness, inflated self-esteem, and flight of
ideas. DSM-IV-TR distinguishes between two kinds of bipolar disorders, depending
on whether the depression has full manic episodes or just ‘hypomanic’ episodes
(episodes that are not as severe as full manic episodes). Table 2 lists and provides a
brief description of the main affective disorders. Our focus in the rest of this section
will be on major depression (MD). Bipolar disorder will not be considered further
here.
Table 2 Affective or mood disorders (modified from Bear et al., 2007 adapted from
DSM-IV-TR (APA, 2000).)
Name
Description
Major depression (MD), also
called major depressive disorder
(MDD); unipolar disorder; major
depressive episode (MDE);
clinical depression
Lowered mood and decreased interest or pleasure
in all activities, over a period of at least 2 weeks
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Dysthymia or dysthymic disorder Milder than major depression, but has a chronic,
‘smouldering’ course, and seldom disappears
spontaneously
Bipolar disorder (Type I); was
called manic-depressive disorder
(see also for mania)
Repeated episodes of mania, or mixed episodes of
mania and depression, hence also called manicdepressive disorder. Mania is a distinct period of
abnormally and persistently elevated, expansive,
or irritable mood and impaired judgement
Bipolar disorder (Type II)
Characterised by hypomania, a milder form of
mania that is not associated with marked
impairments in judgements or performance, but
associated with major depression
Cyclothymia or cyclothymic
disorder
Hypomania alternating with periods of depression
that are not major, i.e. fewer symptoms and
shorter duration
Postnatal depression (PND)
Usually, the depression begins during the first
year of parenthood, and ranges in severity from
mild to severe
Seasonal affective disorder
(SAD)
Depression is more common in the winter months
and in the Northern Hemisphere, which suggests
to some researchers that brain chemistry is
affected by sunlight exposure
3.3 Diagnosing major depression (MD)
Between ordinary low mood and serious depression lie a range of depressive
experiences of varying degrees of severity – that is, there is a continuum. One
important issue for diagnostic schemes is whether to draw a line between ‘ordinary
sadness’ and serious depression and, if so, where this line should be drawn.
DSM-IV-TR (and ICD-10) diagnostic systems are categorical – that is, they are used
to decide whether a particular named disorder is present or not present. In effect, they
draw a line through a continuum of experience. It is a bit like deciding that all men
over the height of 5 ft 6 in (1.68 m) fall into the category ‘tall’, while all those under
this height fall into the category ‘short’.
The DSM-IV-TR criteria for MD are shown in Box 3. Depression that does not meet
the criteria is categorised as subclinical depression, while any depression that does
meet the criteria is categorised as clinical depression.
As you look at Box 3 below, think back to Lewis Wolpert’s account of his depression
(Vignette 1), and consider how the criteria below relate to his experience.
Box 3 Diagnostic criteria for major depressive episode
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(Adapted from DSM-IV-TR (APA, 2000))
The American Psychiatric Association suggest a diagnosis of depression if, during the
same 2-week period, a person experiences five (or more) of the following symptoms,
which must include either or both of the two primary symptoms:
The primary symptoms are:
1. persistent feelings of sadness or anxiety
2. loss of interest or pleasure in usual activities
The secondary symptoms are:
1. changes in appetite that result in weight losses or gains not related to
dieting
2. insomnia or oversleeping
3. loss of energy or increased fatigue
4. restlessness or irritability
5. feelings of worthlessness or inappropriate guilt
6. difficulty thinking, concentrating or making decisions
7. thoughts of death or suicide or attempts at suicide
Note: symptoms should not be counted if:
A. They are the direct physiological effects of a substance (drug of abuse,
or medication) or a medical condition (e.g. hypothyroidism)
B. They would be better accounted for by bereavement (i.e. the loss of a
loved one).
Activity 3 Using diagnostic criteria
Allow 10 minutes
Considering Lewis Wolpert’s depressive episode, and the criteria in Box 3:
a. Which of the criteria were clearly or probably met in Wolpert’s
account?
b. Are there any criteria that there might be some uncertainty about?
c. Were there any experiences in Wolpert’s account that are not
mentioned in the criteria?
View answer - Untitled part
In real life, low mood is a continuum – people can be mildly, moderately or seriously
depressed. Scales other than the DSM are used to assess the level of depression on a
continuum. The Beck Depression Inventory is one such scale.
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Can you think of a situation in which it would be useful to have a scale such as the
BDI?
View answer - Untitled part
Activity 4 Diagnosing major depression
Allow 5 minutes
Jean has lost her beloved husband and consequently has been feeling very low for the
last two weeks. Bill has lost his job and is feeling similarly low. Symptoms 1, 2, 3, 4,
5 and 8 in Box 3 definitely apply to both Jean and Bill. Are they equally likely to be
diagnosed as suffering major depression (MD)? Explain your answer.
View answer - Activity 4 Diagnosing major depression
3.4 Anxiety disorders
Fear, anxiety and worry are part of normal experience and can all be very useful, as
we have seen. However, when they become exaggerated, or attached to inappropriate
stimuli or situations, they can interfere with normal functioning and cause immense
distress. Anxiety disorders are characterised by constant or intense feelings of
apprehension, uncertainty and fear. These feelings are one extreme of a continuum
from ‘normal’ fear to anxiety – the responses differ not in kind but in degree. Both
involve the ‘fight or flight’ system that comes into play in situations of actual or
perceived danger. Table 3 shows a range of anxiety disorders together with brief
descriptions of their symptoms.
Table 3 Anxiety disorders (from Bear et al., 2007 adapted from DSM-IV-TR (APA,
2000)).
Name
Description
Panic disorder (PD)
Frequent panic attacks consisting of discrete periods with the
sudden onset of intense apprehension, fearfulness, or terror,
often associated with feelings of impending doom
Agoraphobia
Anxiety about, or the avoidance of, places or situations from
which escape might be difficult or embarrassing, or in which
help may not be available in the event of a panic attack
Obsessivecompulsive disorder
(OCD)
Obsessions, which cause marked anxiety or distress, and/or
compulsions, which serve to neutralise anxiety in the short
term
Generalised anxiety
disorder (GAD)
At least 6 months of persistent and excessive anxiety and
worry
Specific phobia
Clinically significant anxiety provoked by exposure to a
specific feared object (such as birds or blood) or situation,
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often leading to avoidance behaviour
Social phobia (or
social anxiety)
Clinically significant anxiety provoked by exposure to certain
types of social or performance situations, often leading to
avoidance behaviour
Post-traumatic stress The re-experiencing of an extremely traumatic event,
disorder (PTSD)
accompanied by symptoms of increased arousal and the
avoidance of stimuli associated with the trauma
Some anxiety disorders, such as phobias, appear to be provoked by fear of a specific
danger (Table 3). In others, such as GAD, no specific object is known to pose a threat,
but strong anxiety is chronic, present almost daily for months on end. In the rest of
this section we will focus on GAD.
3.5 Experiencing anxiety
GAD is one of the most prevalent emotional disorders (Figure 1). It has been
estimated that more than 5% of people will be diagnosed with GAD in their lifetime,
and 12% of those who attend anxiety clinics are diagnosed with GAD (Kessler et al.,
2005). Anxiety is also part of mixed anxiety and depression (MAD) one of the most
common emotional disorders (Figure 1). We will return to MAD in Section 4.
The case report in Vignette 2 describes one woman’s experience of GAD.
Vignette 2 Generalised anxiety disorder (GAD) – Suzanna’s story
I have been suffering from GAD for nearly 2 years now.
I am no better now than when I was first diagnosed, and I have to say, that I ended up
feeling very alone and afraid. […] I am on disability living allowance due to the
severity of my symptoms. I’ll list them in the hope that someone else suffering will
see them and realise that they are not alone:











Palpitations
Chest pain
Back pain
IBS [irritable bowel syndrome]
Stomach pain
Breathlessness
Pains in arms and legs
Constant feeling that I’m going to die
Insomnia
Headaches and feelings of tightness in the head
Blurred vision
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There are just too many symptoms to list them all. GAD can manifest itself in so
many different physical ways that you end up not knowing what is real and what is
part of the anxiety […] I ended up going to casualty thinking I was having a heart
attack, so many times. I […] continue to believe my symptoms have physical causes.
The fact that I’m even writing this shows that somewhere inside, I must be aware that
my severe anxiety is causing it. There are just too many symptoms for it to be one
physical illness. Doesn’t help when you’re sat on your own going through it. If I can
help anyone, it is by saying that you must be the first person to help yourself. Be
stronger than I have managed to be and demand the help you need. This is a real
illness and I have been told that it is second only to depression in this country, and yet
I cannot find the help I need.
(Anxiety UK, 2007)
Those suffering from GAD (Figure 11) are sometimes characterised as ‘worriers’,
with daily life dominated by anxious thoughts. Their muscles may be unusually tense,
and they may have hardening of the arteries (Thayer et al., 1996). It appears to be
more common amongst poorer people, those with lower education, and those living in
urban environments. In the USA it is more common amongst young black people
(Blazer et al., 1991), and there is evidence that it is more common in countries in
which there is war or political oppression than in countries at peace (Compton et al.,
1991).
Figure 11 Chronic worry and anxiety characterise GAD.
View description - Figure 11 Chronic worry and anxiety characterise GAD.

Why might GAD be more common in these situations?

These seem to be situations in which people experience a lack of
control over their own destinies and future – about violence, their
own safety, discrimination and lack of opportunity. These are just the
kind of situations where people would be more likely to worry.
3.6 Diagnosing generalised anxiety disorder
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GAD is typically diagnosed if a patient shows anxiety symptoms that do not
adequately fit any of the criteria for the other anxiety disorders listed in Table 3, but
do fulfil those for generalised anxiety disorder. The DSM-IV-TR criteria for GAD are
listed in Box 4.
As you look at Box 4, look back also at Suzanna’s account of her anxiety (Vignette 2)
and think about how her experience relates to the criteria below.
Box 4 Brief diagnostic criteria for generalised anxiety disorder
(Adapted from DSM-IV-TR (APA, 2000))
Criteria A–F need to be satisfied for a diagnosis of GAD.
A. Excessive anxiety and worry (apprehensive expectation), occurring
more days than not for at least 6 months, about a number of events or
activities (such as work or school performance).
B. The person finds it difficult to control the worry.
C. The anxiety and worry are associated with three (or more) of the
following six symptoms, with at least some symptoms present for
more days than not for the past 6 months (Note: only one item is
required in children):
1. restlessness or feeling keyed up or on edge
2. being easily fatigued
3. difficulty concentrating or mind going blank
4. irritability
5. muscle tension
6. sleep disturbance (difficulty falling or staying asleep,
or restless unsatisfying sleep).
A. The focus of anxiety and worry is not about having a panic attack (as
in panic disorder), being embarrassed in public (as in social phobia),
being contaminated (as in obsessive-compulsive disorder), being
away from home or close relatives (as in separation anxiety disorder),
gaining weight (as in anorexia nervosa), having multiple physical
complaints (as in somatisation disorder), or having a serious illness
(as in hypochondriasis), and the anxiety and worry do not occur
exclusively during post-traumatic stress disorder.
B. The anxiety, worry or physical symptoms cause clinically significant
distress or impairment in social, occupational or other important areas
of functioning.
C. The disturbance is not due to the direct physiological effects of a
substance (e.g. a drug of abuse, a medication) or a general medical
condition (e.g. hyperthyroidism) and does not occur exclusively
during a mood disorder, a psychotic disorder or a pervasive
developmental disorder.
Activity 5 Diagnosing types of anxiety
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Allow 5 minutes
Does Suzanna’s experience (in Vignette 2) suggest state or trait anxiety? Explain your
answer.
View answer - Activity 5 Diagnosing types of anxiety
There is evidence that those who have a tendency to be anxious (have trait anxiety)
can benefit from psychotherapy, relaxation and meditation.
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4 Challenges in the diagnosis of depression and
anxiety
People suffering from depression or anxiety often seek informal help at first –
consulting friends, neighbours and family, and relevant websites and books. Only if
the problem persists are they likely to seek professional help. Typically, the
professional consulted will be the family doctor or GP.
People experiencing emotional distress may seek out a GP because they are
experiencing physical symptoms such as back pain, heart palpitations, sleeping
difficulties, tiredness, loss of appetite, etc. For such symptoms, GPs may need to
exclude some conditions, such as hypothyroidism.
GPs often do make independent decisions about whether a patient is suffering from an
emotional disorder or not, though if they feel uncertain, or if the disorder seems very
serious, the patient may be referred to specialists in mental health diagnosis and care,
such as psychiatrists.
Ideally, a GP would have the time and resources to carry out appropriate
psychological and physiological tests, and to spend time assessing anyone who was
suffering from an emotional disorder. However, as the average GP visit in the UK
lasts only a few minutes, this is a counsel of perfection. Indeed a meta-analysis (see
Box 5 for what a meta-analysis involves) of studies involving over 50 000 patients
concluded that GPs do not recognise depression in a significant number of those who
have it, and also frequently diagnose it in people who do not have it (Mitchell et al.,
2009).
Box 5 Research methods: meta-analysis
A meta-analysis (‘meta’ means ‘high-level’ so meta-analysis means ‘high-level
analysis’) considers the results of previous studies (published, and sometimes
unpublished) on a specific topic to reach a more reliable overall conclusion. This is a
very valuable process since it allows researchers to make sense of the often
conflicting information that is presented by individual studies. In addition, metaanalyses can help in understanding precisely why individual studies show different or
conflicting results. For instance, one study may show that Treatment X works, while
another study may show that the same treatment doesn’t work. A meta-analysis might
identify a variable (such as the ‘age of participants’) that explains the discrepancy: the
first study may have been conducted with older people, and the second with younger
people. This would suggest the possibility that Treatment X is effective with older
patients but not with younger ones.
Meta-analyses need to be done carefully to try to make sure that the measures used in
the different studies are comparable. For instance, if an emotional disorder such as
major depression is assessed in different ways in some studies than in others, then this
could confuse the results of the meta-analysis.
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Mitchell et al. (2009) selected studies where GPs were making routine ‘unassisted’
diagnoses – based on their own judgment, ‘without specific help from severity scales,
diagnostic instruments, education programmes, or other organisational approaches’ –
that is, the way GPs normally make diagnoses.
The accuracy of the GPs’ diagnoses of depression had been assessed independently in
each of the studies included in the meta-analysis, using DSM or ICD criteria for
depression. Thus Mitchell and his colleagues had information about the extent to
which GPs got the diagnosis of depression right or wrong.
They found that: ‘In general, a motivated GP in an urban setting (where the rate of
prevalence of depression is 20%) would correctly diagnose 10 out of 20 cases,
missing 10 true positives. The GP would correctly reassure 65 out of 80 nondepressed individuals, falsely diagnosing 15 people as depressed’.
Activity 6 Misdiagnosing depression
Allow 5 minutes
What is the percentage of true cases of depression misdiagnosed? Are these false
negatives or false positives?
View answer - Untitled part
What is the percentage of non-depressed people incorrectly diagnosed as depressed?
Are these false negatives or false positives?
View answer - Untitled part
The number of people misdiagnosed as false negatives or false positives (from above,
15 + 10 = 25 out of 100, 1 in 4, or 25%) is therefore substantial. Moreover, as GPs
prescribe antidepressant drug treatment and make referrals for counselling and
therapy, this means some people who need treatment will not be offered it, while
others may be prescribed treatment they do not need.
Where drug treatments are offered to false positives, this can be problematic, as drugs
typically have side effects and can be difficult to come off. Fortunately the evidence
also suggests that GPs are less likely to misdiagnose serious cases of depression
(Mitchell et al., 2009).
The above should not be seen as a criticism of the diagnostic abilities of GPs. As
Tyrer (2009) points out, the diagnosis of depression is fraught with difficulty even for
experts, so it is not surprising that misdiagnosis, especially of milder and moderate
cases of depression, occurs. The fact that depression is often mixed with anxiety, as
we consider below, may make diagnosis even trickier.
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Activity 7 Factors affecting diagnosis of emotional disorders in a
primary care setting
Allow 20 minutes
Take a few minutes to think about, and make a list of, factors that might help a GP
(working in the normal way, without assistance) to assess a patient more accurately
for an emotional disorder such as depression. This activity should help you appreciate
the factors at play in a primary care setting that may impact on diagnosis.
View discussion - Activity 7 Factors affecting diagnosis of emotional disorders in a
primary care ...
Some people complaining of somatic symptoms may not be sensitive to, or may be
unwilling to acknowledge, emotional suffering in themselves. Some may feel that
somatic symptoms will be taken more seriously by the medical profession, or be more
amenable to medical treatment. Hence they may be more likely to mention these to a
doctor than feelings of anxiety and depression. Personal and cultural values may come
into play here, too – for instance, the evidence suggests that there may be a gender
difference, with men less likely to report emotional distress than women.
4.1 Are the diagnostic categories correct?
According to DSM-IV-TR, if the criteria for two or more disorders – such as MD and
GAD – are each satisfied in the same person, the disorders are comorbid.
In fact, MD and GAD are often comorbid. Figure 12 shows the odds ratios for having
an anxiety disorder at the same time as major depression. Box 6 explains what an
odds ratio is if you are not familiar with this term.
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Figure 12 Likelihood that a comorbid anxiety disorder is also present in patients diagnosed with major
depression (MD).
View description - Figure 12 Likelihood that a comorbid anxiety disorder is also
present in patients ...
Box 6 Odds ratio
Imagine that the chances in the USA of adult men having GAD are on average 1 in
100. But what of the subset of adult men who already have MD? What are the
chances that such men will have GAD as well as MD? An odds ratio tells us about the
increase in the chance that such men will have GAD, already having MD. If having
MD increases the chances of having GAD from the usual 1 in 100 to 8.2 in 100, then
the odds ratio for having GAD when you have MD is 8.2. If having MD has no effect
at all on the chances of having GAD then the odds ratio is 1.00 (it does not affect the
odds). An odds ratio of 1.05 means for the population of men with MD the chances of
having GAD are increased by 5%. The further away from 1 the odds ratio is, the
stronger the effect.

What might this kind of pairing between MD and GAD suggest?

That there is some connection between the two conditions. For
instance: (i) one causes the other; (ii) both are due to a common
cause; (iii) there is just one underlying condition with a range of
symptoms, with some symptoms matching the (artificially set up)
criteria for one condition and others matching the criteria for the other
condition.
Activity 8 Identifying an odds ratio
Allow 5 minutes
Look at Figure 12. What is the odds ratio that ‘any anxiety disorder’ will be present in
people who have major depression? What does this mean?
View answer - Activity 8 Identifying an odds ratio
In practice, it is increasingly recognised that in many cases a person has some
symptoms of depression (but not enough to justify a diagnosis of depression), and
some symptoms of anxiety (but not enough to justify a diagnosis of anxiety). Neither
DSM-IV-TR nor ICD-10 provide for the proper diagnosis of such a condition.
However, an increasing number of researchers recognise this as mixed anxiety and
depression disorder (MADD), also called mixed anxiety and depression (MAD – see
Figure 1) or cothymia (Tyrer, 2001). Indeed MAD was found to occur in around 55%
of all those suffering from an emotional disorder (or common mental disorder)
(McManus et al., 2009), making it the most common emotional disorder by far.
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The existence of strong comorbidity between anxiety and depression, and mixed
anxiety and depressive disorder, have led some researchers to suggest that these
disorders lie on an anxiety–depression continuum or spectrum.
Indeed there is evidence to suggest that ‘cases’ of disorder might map onto a single
spectrum of ‘counts of mental symptoms’, with no evidence for clustering of
symptoms into disorders such as those proposed by DSM-IV-TR and ICD-10 (DasMunshi et al., 2008; Melzer et al., 2002).
Using a CIS-R scale (‘Clinical Interview Schedule – Revised’ scale – see Box 7),
Das-Munshi et al. (2008) assessed the presence of symptoms of mental disorder and
mapped them onto ‘recognised’ depression and anxiety disorders such as MD, GAD,
MAD and comorbid anxiety and depression.
Box 7 Clinical Interview Schedule – Revised (CIS-R)
The CIS-R is a structured interview schedule used in national surveys such as the
Adult Psychiatric Morbidity in England, 2007: results of a household survey
(McManus et al., 2009) to assess neurotic symptoms and common mental disorders in
the population. For each interviewee, the severity of symptoms such as fatigue,
concentration and forgetfulness, sleep problems, irritability, depressive ideas,
depression, anxiety, panic, worry about physical health, compulsions, obsessions and
so on, is scored on a scale of 0–4 (0–5 in the case of depressive ideas). The scores are
summed to give an overall severity score: a score of 12 or more indicates a significant
level of symptoms, and a score of 18 or more suggests treatment is needed. In the
APMS (2007) interviewees’ answers to the CIS-R were also used to derive ICD-10
diagnoses of GAD, MD, phobias, OCD and panic disorder. MAD was defined as
having a CIS-R score of 12 or more but falling short of the criteria for any other
common mental disorder.
The distribution of CIS-R scores they obtained for the four different disorders (and for
‘no diagnosis’) is shown in Figure 13.
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Figure 13 Box plot distributions of CIS-R symptom scores for five diagnostic groups. In a box plot
distribution 50% of the scores obtained (between 25%–75%) lie inside the box. The horizontal line across
each box shows the median score (see Box 1). The bars above and below the box show the range of scores in
each case, from minimum (at bottom of bar) to maximum (at top of bar).
View description - Figure 13 Box plot distributions of CIS-R symptom scores for five
diagnostic groups. ...

The higher the CIS-R score, the more serious on average a disorder is
likely to be. On this basis, looking at Figure 13, which of the four
disorders would appear to be least serious and which would appear to
be most serious?

Mixed anxiety-depression would be least serious; comorbid
depression and anxiety would be most serious.
Interestingly, such critiques appear to be having some impact. The next version of the
DSM (DSM-5, published 2013), while still applying a categorical approach, proposed
a new disorder called mixed anxiety depression.
Activity 9 Using the diagnostic categories
Allow 10 minutes
Think back to Suzanna’s case in Vignette 2. Does it satisfy DSM-IV-TR criterion C
for the diagnosis of GAD (Box 7)? Give reasons for your answer.
View answer - Activity 9 Using the diagnostic categories
4.2 Medicalising sadness?
Depressive disorders are amongst the most commonly diagnosed mood disorders.
Indeed by some accounts there is a veritable epidemic of depression all across the
world (Murray and Lopez, 1996).
Some critics have suggested that the apparent increase in depressive disorders may be
due to changes in the criteria used to diagnose depression. The main issue here is how
to distinguish depressive disorder from normal suffering. DSM’s own definition of a
mental disorder is that a disorder involves a dysfunction in an individual; hence an
expected response to a stressor should not be considered a disorder. Critics argue that
DSM’s own criteria subvert this definition – DSM lists the symptoms that must be
present for a given diagnosis, but ignores the context in which the symptoms
developed.

Why might context be important here?
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 In some contexts the kinds
of symptoms listed for a diagnosis of
depressive disorder might be a normal and expected response to a
stressor; in other words, the suffering is ‘normal’, not ‘dysfunctional’.
DSM-IV-TR is thus accused of medicalising ordinary, in the sense of ‘to be expected
in the circumstances’, sadness; that is, of having criteria that allow conflation of the
kind of sadness expected after a loss or disappointment, with the altogether different
phenomenon of long-term and apparently inexplicable ‘melancholia’ (Horwitz and
Wakefield, 2007). For example, DSM-IV-TR, while recognising the legitimacy of
depressive symptoms for 2 months following bereavement in the shape of the loss of a
loved one, does not recognise that other losses (e.g. of a job, a marriage) can also be a
form of bereavement and lead to depressive symptoms.

What is the effect of DSM-IV-TR ignoring other contexts that could
legitimately precipitate a loss or bereavement response?

Depressive disorder (rather than context-related sadness or grief)
would be diagnosed. This could lead to inflation of the number of
cases of depressive disorder diagnosed and referred for treatment.
Ordinary sadness is a common human experience that may have an adaptive function
and for most people it dissipates on its own without treatment in days or weeks.
Nevertheless, it is probably the case that many people experiencing it find it
unacceptable and unbearable, and welcome any diagnosis that allows treatment and
relief from the symptoms.
Indeed many people now appear to see low mood and anxiety as a ‘disease’ that can
and should be cured as quickly as possible with drugs. Thus some of those who
experienced low mood and anxiety consequent on severe financial set-backs or job
losses in the UK recession of 2009 apparently ‘pressured’ their doctors into
prescribing antidepressant and other pills, wanting a ‘quick fix’, even though other
forms of help (such as advice on how to cope with debt) might have been more
appropriate.
It is difficult to argue the rights and wrongs of this, and this course certainly cannot do
full justice to such a complex issue.
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Conclusion
While acknowledging the biological antecedents and value of emotions such as
sadness and anxiety, and the possibility that ‘ordinary’ sadness and anxiety may now
be over-diagnosed as disorders and over-medicalised, we must not forget that we are
dealing with a spectrum of severity. Thus, far from being ordinary, major depression
is an extreme form of sadness – described by those like Lewis Wolpert who have
experienced it (Vignette 1) as ‘malignant sadness’ (Wolpert, 2001). There can be no
doubt that severe depression is a disorder, associated as it is with self-harm, inability
to work and even suicide. What might underlie such disorders, and why do some
people experience such extremes of sadness, and of other emotions such as anxiety,
while others do not? This question is addressed in the related OpenLearn course
Understanding depression and anxiety, where we consider the possible causes of
emotional disorders.
Any examination of emotional disorders needs to done against the backdrop that
emotional phenomena have evolved over millions of years, and that negative as well
as positive emotions have functions. There is evidence that sadness and worry can be
beneficial.
The concept of the ‘triune brain’ postulates that the human brain can be thought of as
‘three brains’. Some are ‘ancient’ in evolutionary terms, while others are newer. Parts
of our brains are very similar to those in other animals, and include the brain bases of
emotional responses such as the fear response.
There is good evidence for the universality of emotions such as fear, anger, sadness
and joy amongst humans, as a result of shared biological bases. However, culture
affects which emotions are displayed and what they are associated with.
Observations of the behavioural tendencies of animals in situations of defeat and
outranking have inspired important insights into human depression and anxiety.
DSM-IV-TR distinguishes between affective (or mood) disorders and anxiety
disorders. First-person experiences of major depression (MD) and generalised anxiety
disorder (GAD) are described and considered in the light of DSM criteria for these
disorders.
There are established diagnostic criteria for deciding whether particular affective or
anxiety disorders are present in an individual or not. However, the process of
diagnosing such disorders is not straightforward. This is an important issue, not just
for the treatment of patients suffering from emotional disorders (for instance, GPs get
a significant proportion of diagnoses of major depression wrong) but also for those
trying to clarify the risk factors for these disorders.
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Tyrer, P. (2009) ‘Are general practitioners really unable to diagnose depression?’, The
Lancet, vol. 374, pp. 589–90.
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Wolpert, L. (2001) Malignant Sadness: The Anatomy of Depression, London, Faber
and Faber.
Wolpert, L. (2009) ‘Experiencing depression’, in Pariante, C.M., Nesse, R.M., Nutt,
D. and Wolpert, L. (eds) Understanding Depression: A Translational Approach,
Oxford, Oxford University Press, pp. 1–5.
World Heath Organization (WHO) (2007) The International Statistical Classification
of Diseases and Related Health Problems, (10th Revision) (ICD-10) Chapter V
‘Mental and Behavioural Disorders’ [online],
http://apps.who.int/classifications/apps/icd/icd10online/ (Accessed June 2010).
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Acknowledgements
This course was written by Saroj Datta and Claire Rostron.
Grateful acknowledgement is made to Katherine Leys for coordinating the Research
Methods boxes throughout this course.
Except for third-party materials and otherwise stated in the acknowledgements
section, this content is made available under a Creative Commons AttributionNonCommercial-ShareAlike 4.0 Licence.
The material acknowledged below is Proprietary and used under licence (not subject
to Creative Commons Licence). Grateful acknowledgement is made to the following
sources for permission to reproduce material in this course:
Course image: © Richard Paisley/Doctor Stock/Getty Images.
Table
Table 1: adapted from Brown et al. (1995) ‘Loss, humiliation and entrapment among
women developing depression: a patient and non-patient comparison’, Psychological
Medicine, Cambridge Journals.
Figures
Figure 1: adapted from ©2009 The Health and Social Care Information Centre, Social
Care Statistics. All rights reserved; Figure2(a) and 2(b): copyright unknown; Figure 6:
© Pam Smit/Alamy; Figure 9: adapted from Dickerson, S.S. and Kemeny, M.E.
(2004) Mean Cortisol Effect Size for Studies Using Passive Tasks, American
Psychological Association; Figure 10: Copyright © Antonia Reeve/Science Photo
Library; Figure 11: © Richard Paisley/Doctor Stock/Getty Images; Figure 12: adapted
from Hirschfield, R.M.A. (2001) ‘The comorbidity of major depression and anxiety
disorders: recognition and management in primary care’, Primary Care Companion to
the Journal of Clinical Psychiatry, Physicians Postgraduate Press Inc.; Figure 13:
adapted from Das-Munshi, Jayati, et al. (2008) ‘Public health significance of mixed
anxiety and depression: beyond current classification’, British Journal of Psychiatry,
The Royal College of Psychiatrists.
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inadvertently overlooked, the publishers will be pleased to make the necessary
arrangements at the first opportunity.
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Activity 1 Identifying features of different
emotions
Answer
The position of the ears, the tail and the height of the body are all different. The
aggressive dog stares straight ahead; the submissive dog does not. The hairs on the
back of the aggressive dog are raised. You may have noticed other differences too.
Back
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Activity 2 The pathways of the fear reaction
Answer
(a) C; (b) E.
Back
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Untitled part
Answer
a. All of criteria 1–9 appear to have been met.
b. It is interesting that a change of drug preceded Wolpert’s episode; he
also had a medical condition (atrial fibrillation). We don’t have any
information about the extent to which these were responsible for any
of the symptoms he experienced – so we don’t know if item (A) in the
criteria in Box 3 applied or not.
c. He mentions physical (somatic) symptoms and deteriorating memory
(though the latter could perhaps be covered by criterion 8).
Back
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Untitled part
Answer
In studies where researchers are interested in the efficacy of a particular drug
treatment or other intervention, they need to assess the severity of the depression
before and after the treatment or intervention. Scoring on a scale such as the BDI
would allow such an assessment.
Back
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Activity 4 Diagnosing major depression
Answer
No, they are not. Jean is unlikely to be diagnosed with MD because criterion B in Box
3 specifically excludes those whose symptoms may be linked to the loss of a loved
one – which would appear to apply in her case. However, Bill would be diagnosed
with MD, as job loss and consequent feelings of bereavement are not allowed for in
the DSM-IV-TR criteria for MD.
Back
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Activity 5 Diagnosing types of anxiety
Answer
Susanna’s anxiety is not temporarily elicited by particular circumstances, after which
it disappears, as would be the case in state anxiety. Her anxiety seems to be everpresent, so it is like ‘trait anxiety’.
Back
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Untitled part
Answer
10 out of 20, that is 50%, of people are misdiagnosed as OK, even though they are
depressed. These are false negatives.
Back
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Untitled part
Answer
15 out of 80, that is 18.75%, of people who are not depressed are incorrectly
diagnosed as depressed. These are false positives.
Back
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Activity 8 Identifying an odds ratio
Answer
The odds ratio that ‘any anxiety disorder’ will also be present in people who have
major depression is 5.1. This means that the chance of ‘any anxiety disorder’ being
present is 5.1 times higher in people who have major depression, compared to the
normal chance of having ‘any anxiety disorder’.
Back
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Activity 9 Using the diagnostic categories
Answer
Yes, her case appears to satisfy criterion C. Suzanna has at least three of the
symptoms listed, and she has suffered from GAD for over 6 months. The symptoms
she has include: (6) sleep disturbance (she mentions insomnia); (5) muscle tension
(she mentions ‘feelings of tightness in the head’) and (1) feeling keyed up or on edge
(she mentions ‘constant feeling that I am going to die’, which could fit with this).
Back
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Activity 7 Factors affecting diagnosis of
emotional disorders in a primary care setting
Discussion
You may have thought of some of the following factors or come up with others:








The GP is able to spend enough time with patient to probe in a
sensitive way and explore if there are any underlying issues (e.g.
somatic or social) if the patient appears upset or worried.
The GP is sensitive to emotional signals from the patient.
The GP has specific mental health training.
The GP knows of, and can apply, the biopsychosocial approach.
The patient recognises, and is willing and able to speak about, his/her
personal emotional distress.
The GP is familiar with the patient (i.e. the patient is not a new, but is
a regular visitor to the surgery) so is aware of what is normal or not
for the patient.
The GP has known the patient or patient’s family for a while and
knows the patient’s medical issues.
Having one of the patient’s friends or family members present – they
may be able to provide another perspective on the patient’s condition.
Back
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Figure 1 Prevalence rates in England in
2007 of a range of emotional disorders (also
known as common mental disorders) by
gender. MAD: mixed anxiety and depression;
GAD: generalised anxiety disorder; MD:
major depression; OCD: obsessive
compulsive disorder.
Description
The figure is a vertical bar chart, showing data for six emotional disorders from a
sample of approximately 3600 men and 3800 women. The horizontal axis is labelled
type of emotional disorder and is marked MAD, GAD, MD, phobia, OCD, and panic
disorder. The vertical axis is labelled prevalence rate per 100 adults and is marked
from zero to 12 at intervals of 2 units. For all the disorders, prevalence rates for
women exceed those for men. MAD has the highest prevalence rates, at 11 per 100
for women and 7 for men. The figures for GAD are considerably lower, at 5.2 for
women and 3.4 for men, while those for the remaining disorders are lower still. For
MD, rates are 3 for women and 2 for men; for phobia, 2 for women and 1 for men.
The prevalence rates for OCD and panic disorder are also around 1 for men, and only
slightly higher in women.
Back
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Figure 2 Dog showing (a) aggressive and (b)
fearful postures.
Description
The figure comprises two drawings. Part (a) shows a dog standing upright, looking
straight ahead with its ears pointed, and its tail held high. The fur on the dog’s back is
also raised. Part (b) shows a dog with its chest close to the ground, its head angled
upwards and ears held back. Its front legs bent and extended forward and its back is
arched and smooth, with the rear end raised and tail hanging low.
Back
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Figure 4 The triune brain, showing the socalled reptilian brain, the limbic brain and
the neocortex.
Description
The model of the brain is separated into three parts: the lower part is the so-called
reptilian brain, comprising the brainstem and cerebellum; above this is shown the
limbic brain, which includes the amygdala, thalamus, hippocampus and
hypothalamus. The third, and largest part is the neocortex, which comprises the
cerebral hemispheres and includes the prefrontal cortex.
Back
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Figure 5 Information about emotional
stimuli reaches the amygdala via a direct
pathway from the thalamus (‘low road’) as
well as by a pathway from the thalamus to
the cortex (‘high road’) to the amygdala.
Description
The diagram comprises three boxes linked by arrows: the one on the left is labelled
thalamus; the one on the right is labelled amygdala and the one at the top of the
diagram is labelled cortex. A black arrow denotes an emotional stimulus arriving at
the thalamus and another black arrow, emerging from the amygdala, denotes
emotional responses. A blue arrow leading directly from the thalamus to the amygdala
is labelled ‘low road’ and a sequence of red arrows from the thalamus to the amygdala
via the cortex is labelled ‘high road.
Back
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Figure 6 Hunter-gatherers today: A group of
Khoisan people of the Kalahari desert
singing and dancing around their campfire.
Description
The photo shows two members of the group dancing; the others are sitting on the
ground watching, and some of them are clapping.
Back
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Figure 7 Rhesus macaques: the infant son of
a subordinate female (who is out of the
frame) has been kidnapped and is being
mistreated by a dominant female. The infant
was distressed and his mother agitated but
unable to intervene to rescue him. After some
hours the subordinate female managed to
snatch her baby back when the dominant
female let go of him.
Description
The first in this sequence of four photos shows the infant with its mother, the
subordinate female. The second photo shows the infant on the ground being
mistreated by the dominant female. In the third photo, the infant is suspended,
apparently being held at the neck by the dominant female. The last photo shows the
infant seated with its mother, in contact with her abdomen and facing forward.
Back
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Figure 8 A young male rhesus macaque
wounded in a fight with other males showing
submissive posture and fear grimace.
Description
The animal is in a crouched position and baring its teeth. It has a fresh wound on its
right thigh.
Back
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Figure 9 Mean (+/− SEM) change in cortisol
levels in potentially stressful situations.
Values above 0.0 indicate a rise in cortisol
levels. * denotes that the change is
statistically significant. Key to terms: Passive
tasks –tasks such as watching a film that do
not require cognitive responses; Motivated
performance – tasks such as delivering a
speech or solving an arithmetical problem
that require cognitive responses and
achievement of a goal; Uncontrollability – a
situation of ‘forced failure’ where
participants have no chance of succeeding
despite their best efforts, for example where
too little time is given to complete a task;
social evaluative threat – occurs when an
aspect of self (such as ability) could be
negatively judged by others.
Description
The figure is a vertical bar chart showing how cortisol levels change in response to
different types of acute stressor. The vertical axis is labelled change in cortisol level;
and is marked in arbitrary units from minus 0.4 to 1.2 at intervals of 0.2 units. The
two control conditions, passive tasks and motivated performance, each produced a
small reduction in cortisol level of around 0.1 units, while the three stressors produced
statistically significant increases in cortisol levels, as follows: motivated performance
with uncontrollability, 0.3 units; motivated performance with social-evaluative threat,
0.5 units; and motivated performance with social-evaluative threat and
uncontrollability, 0.9 units.
Back
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Figure 10 Lewis Wolpert (1929–).
Description
This photo is a portrait of Lewis Wolpert in late middle age.
Back
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Figure 11 Chronic worry and anxiety
characterise GAD.
Description
This photo shows a woman’s face expressing worry and anxiety.
Back
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Figure 12 Likelihood that a comorbid
anxiety disorder is also present in patients
diagnosed with major depression (MD).
Description
The figure is a vertical bar chart showing the odds ratio for having each of five major
depression and anxiety disorders. The vertical axis is labelled odds ratio and is
marked from zero to 9 at intervals of one unit and the bars are labelled with the names
of the corresponding disorders along the horizontal axis. From the highest to the
lowest, the odds ratios are: GAD, 8.2; PTSD, 6.0; any anxiety disorder, 5.1; panic
and/or agoraphobia, 5.0; and social phobia, 3.3.
Back
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Figure 13 Box plot distributions of CIS-R
symptom scores for five diagnostic groups. In
a box plot distribution 50% of the scores
obtained (between 25%–75%) lie inside the
box. The horizontal line across each box
shows the median score (see Box 1). The bars
above and below the box show the range of
scores in each case, from minimum (at
bottom of bar) to maximum (at top of bar).
Description
The vertical axis is labelled CIS-R score and is marked from zero to 50 at intervals of
10 units. The diagnostic groups are labelled along the horizontal axis. From the
highest to the lowest, the median CIS-R scores and their ranges are: comorbid
depression and anxiety, 30, from 11 to 49; depression, 20, from 10 to 38; anxiety, 18,
from 2 to 41; MAD, 14, from 10 to 28; and no diagnosis, 2, from zero to 10.
Back
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